Background: The complexity of health systems places high demands on patients. Often, health systems fail to meet the varying cognitive abilities of patients to support them to navigate through the system successfully. The World Health Organization identified education as one of the most influencing factors on health literacy (HL). This study aims to analyze the association between education level and HL in Germany using survey data from the IPHA project (Integrating the Population Perspective into Health System Performance Assessment). 

Methods: A survey was conducted among 32,000 statutorily insured adults of one sickness fund in Germany. HL was measured with the German version of the HLS-EU-Q16. Questionnaire items were transferred into a HL score ranging from 0 to 50. Education levels were assessed according to the International Standard Classification of Education. Age and gender were used as controlling variables. A multiple linear regression model was computed stratified for gender. Statistical significance was analyzed using one-factor analyses of variances (ANOVA).

Results: Overall, 1,004 participants were included in the analysis (56.4 years ±18.7, 56.3% female). Education level was high for 34.4%, medium for 42.6% and low for 13.1%. In total, 138 (13.7%) respondents showed inadequate, 376 (37.5%) problematic, 398 (39.6%) sufficient and 92 (9.2%) excellent HL. The mean HL score was 32.6 (±7.1). Correlation coefficients resulted in .015 for the total sample, .037 for female and .008 for male. The ANOVA showed significant differences between age groups (.011) and education levels (.017).

Conclusion: In this study, differing to previous findings, a weak association was found between education and HL. Furthermore, sex-specific differences became visible. Stratification by gender revealed a stronger correlation of the analyzed variables among women compared to men. Promoting education targeted for different population groups (age, gender) can therefore influence health literacy and increase health equity.